The State Of Medical Care, 1984

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Yes. One of the new drugs—isoniazid, discovered in 1950—virtually overnight made tuberculosis a readily curable disease. Research was really paying off. But it cost big bucks. We began putting together big hospital complexes and groups to do the research, all very expensive. Out of this, furthermore, came two related developments. One was that we decided that people who worked in hospitals, who had in the past been very poorly paid, should get living wages just like everybody else. And because it is a very labor-intensive industry, when we began to pay decent wages to orderlies, people who swept the floor, nurses and nurses aides, and the rest, that shot the price up enormously. The second outcome had to do with the new scientific knowledge we were acquiring. In the old days there was just so much the doctor could do; now he can do far more—but it costs money.

Most patients, if they are really sick, don’t care about cost. “Doc, I don’t care what it costs,” they say. “I want the best.”

You mean because there is more the doctor can do, he must do it all, touch all bases?

In many instances, yes. When I was in my residency at New York Hospital back around 1950, if you came in with high blood pressure, there were only a couple of tests I could give you to make sure that was indeed what you had, and they would take only an hour. Assuming they were negative, I would announce that you had high blood pressure and tell you to lose weight, avoid stress, and take phenobarbital. Period. But my God, if you come in today with hypertension, I know there are over thirty different potentially remediable causes. Testing you to find whether any of them is involved is expensive, but I have to go that route because the payoff is so high if I find any of them. Even if I don’t, I’ll end up prescribing drugs for you that are much better than phenobarbital—but they cost more. Furthermore, I would have to charge much more than in the old days because it has taken me so much longer to get the answers I must have. Back in my time a resident used to be able to work up ten high-blood-pressure patients in one day; now he’s got a tough time finishing just one. So the human cost has multiplied too.

Don’t doctors often give more tests than they really have to, though?

Sometimes. But the catch is that they often get a tremendous windfall of information from these new, automated machines that analyze samples even if not requested to. The way the modern lab works, it doesn’t really cost all that much more to add the extra tests—it’s all done on the same blood sample or whatever. Trouble is, the outcome of one test may be suspicious enough to require another test. If I’ve requested your blood calcium, the report may show that your calcium is indeed up—but it may also tell me that your uric acid is way up too. So I must ask myself, Does this fellow have gout? Answering that one will cost you another fifty dollars or more.

You once wrote about a family physician who kept track not long ago of what the actual cost was of all the treatment, tests, and medication that he had authorized just in one day—and it came to $13,400.

He was amazed and upset by that figure. But he felt it was inevitable. He felt he’d had no choice in virtually every case. On the other hand, I do believe that we can educate physicians to be more selective in the tests and treatments they generate. A group of us did a study recently of the costs of tests, to see if those big expensive gadgets like the CT scanner—which provides a particularly revealing kind of internal body image—were really responsible for the increases. We concluded they were not. It’s the smaller tests being given in such profusion that really hurt your pocketbook. We must try to get doctors to cut down on them. I think we are using some technologies unwisely, and perhaps using too many of them sometimes. But I must add one point here. Often the reassurance you get when all those tests come back negative is worth every penny to you. Let’s say you come to me with a terrible cough and tell me you think you may have cancer of the lung.

I’ll surely want all the tests.

You will indeed. So maybe I’ll come back to you in four days and say I have good news: You have no cancer, it’s an old calcific lesion you’ve had for twenty years, and you can forget about it. It may cost several thousand dollars to tell you that. But it’s a pretty important piece of knowledge for you to have.

Insurance that pushes us toward hospitals helps to drive costs through the roof. We must change the way medical care is reimbursed.

And another point is that my insurance will pay for most of it anyway.